Meta-synthesis of qualitative studies to explore fathers’ perspectives of their influence on children’s obesity-related health behaviors

Background In nursing research and practice, there is a paucity of information about how fathers perceive their role in shaping their children’s health behaviors. Most studies on the parental factors affecting children’s health behaviors have focused on the role of mothers. However, recent studies showed that fathers’ health behaviors can influence those of their children. Therefore, the aim of this study was to synthesize existing qualitative studies to explore fathers’ perspectives regarding how they influence children’s obesity-related health behaviors. Methods We conducted a descriptive meta-synthesis. To retrieve relevant articles, we used databases including PubMed, CINAHL, and Web of Science. Only qualitative studies published in English-language peer-reviewed journals, targeting fathers of children aged 2–18 years, and focusing on fathers’ perspectives were included. All the quotes collected from the studies were reviewed and coded, and thematic analysis was used to derive themes. Results Article screening and review yielded a total of 13 qualitative studies, from which the following themes emerged: (1) fathers’ parenting practices and role-modeling behaviors, (2) fathers’ roles in their relationships with their family members, and (3) fathers’ resource-seeking behaviors and contributions to their home food environment. Fathers were aware that their parenting practices and role-modeling behaviors could influence their children’s health behaviors. Furthermore, fathers recognized the importance of their relationships with family members, which was reflected in their family roles; that is, whether they took responsibility for childcare and household work, whether their parenting practices were similar to those of their spouses, and whether they involved their children in their activities. Fathers also reported their resource-seeking behaviors as well as their contribution to the home food environment, which affected their children’s health behaviors. Conclusion Fathers’ perspectives on their influence on children’s health behaviors reveal their unique paternal role in influencing children’s health behaviors. Fathers’ perspectives could be incorporated into future nursing research to examine the relationship between fathers’ roles and children’s health behaviors to develop better health intervention programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-024-01728-z.


Introduction
Childhood obesity poses a threat to global public health.Numerous interventions have been developed and implemented to combat childhood obesity with mixed shortterm effects [1,2].Multiple factors influence children's health behaviors, including diet, physical activity, and sedentary behavior; among these, parents play a significant role in shaping their children's health behaviors.Investigations of parental influence on children's health behaviors have revealed multiple factors and their relationships with children's health behaviors [3,4].
Parental influence on children's health behaviors is often assessed in terms of parents' parenting practices, which comprise their behavioral strategies for interacting with their children [5].Parenting practices, including applying specific rules to reach a compromise with their children, such as monitoring and setting limits on specific behaviors, can promote healthy behaviors in children [6,7].Conversely, parenting practices involving stringent rules to control children's behaviors without a prior discussion or compromise [8] or those involving excessive permissiveness or minimal rules may promote unhealthy behaviors among children [9].
Despite the scholarly consensus on parental influence on children's health behaviors, a notable issue with such investigations is that they have mainly focused on the role of mothers or female guardians [10].A systematic review of observational studies found that fathers were less likely to participate in research on parenting practices related to childhood obesity [11].Furthermore, fathers were involved in a limited number of intervention programs designed to improve their children's health behaviors and address childhood obesity [12].
There may be some reasons for the underrepresentation of fathers in such studies.Traditionally, parents' roles were more clearly divided, as the mother took primary responsibility for childcare, whereas the father took the role of the breadwinner [12].The differences in the socially constructed roles of fathers and mothers may have influenced fathers' research participation.Mothers commonly consider themselves the main caregivers of their children; thus, they may tend to participate in such research more actively.However, while this rationale may apply to traditional families, family dynamics have changed over time, and family roles have become more complicated [13].For instance, both parents often work outside the home and share childcare responsibilities; thus, the mother is no longer the only main caregiver [14].Consequently, an approach that mainly targets mothers may be limited in capturing the dynamics of parental influence on children's health behaviors.Consistent with this assumption, it was found that the parent's sex is a possible moderator for understanding parental influence on children's health behaviors and obesity in a systematic review of observational studies [15].
Emerging evidence suggests that fathers' unhealthy feeding practices predict the increase in children's body weight and that fathers' diet quality is positively associated with the overall quality of children's food consumption [16].Notably, one study reported that the father's weight had a greater impact on the likelihood of children being obese than the mother's weight [17].Despite the potential influence of fathers on their children's health behaviors and weight, the literature on nursing research and practice lacks relevant information on ways to mitigate fathers' potential negative impact on children's health behaviors.Nevertheless, several qualitative studies have explored fathers' parenting, attitudes, perceptions, and roles in children's health behaviors [18][19][20].Synthesizing previous qualitative studies would provide a more in-depth understanding of how fathers perceive their influence on their children's health behaviors.A qualitative meta-synthesis is the systematic integration of results from qualitative studies to provide a more comprehensive exploration of the complex phenomenon [21].Therefore, this study aimed to synthesize qualitative results to explore fathers' perspectives regarding how they influence children's obesity-related health behaviors.The research question was: What are fathers' perspectives about their influence on children's health behaviors related to childhood obesity?

Methods
We utilized the qualitative meta-synthesis methodology to synthesize the outcomes of qualitative studies that explored fathers' perspectives on their influence on their children's health behaviors.This research was performed in accordance with the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guideline [22] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guideline [23].

Identification and selection of relevant articles
The relevant articles were identified by retrieving articles from database searches and manual searching for other sources, including review articles identified through the initial search.We searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases using combinations of the following search terms: (father OR paternal) AND (role OR perspective) AND (children OR child) AND (health behavior OR eating OR physical activity OR sedentary behavior).We did not use search terms pertaining to the study design because they may limit the relevant literature search.
We included qualitative research articles that met the following criteria: 1) the study focused on fathers' perspectives on their influence on children's health behaviors; 2) the study targeted fathers of children aged 2-18 years; and 3) the article was written in English and published in a peer-reviewed journal published by July 2023.We excluded articles based on the following criteria: 1) the study used a study design other than a qualitative study design; 2) the study included both parents and did not differentiate between the outcomes derived from each parent's statements; and 3) the study targeted the families of children with health conditions and their influence on these children's eating behaviors or physical activities.We also excluded articles on other people's (e.g., the mother or healthcare providers) reports on fathers' influence on children's health behaviors because we solely focused on fathers' perspectives.Finally, we did not include studies focusing on prevention or management of childhood obesity because we aimed to explore fathers' perspectives on their influence on children's health behaviors rather than their efforts to improve their children's behaviors.
After importing all the articles into EndNote, author M.J., who has experience with systematic review studies, performed the initial screening by deleting duplicate articles and excluding non-qualitative studies and non-English articles.After the initial screening, author M.J. and co-author N.D. (a trained graduate student), independently reviewed the abstracts and full texts, if necessary, for further screening.Subsequently, the two co-authors compared their screening results and reached a consensus through discussion of any discrepancies.

Quality assessment
We performed a quality assessment using the Checklist for Qualitative Research, which is a part of the Joanna Briggs Institute's Critical Appraisal tools [24].This checklist helps assess the methodological quality of a qualitative study and determine the extent to which the study has addressed the possibility of bias in its design, conduct, and analysis.This assessment tool comprises 10 questions regarding the quality of any type of qualitative research, with responses such as "yes, " "no, " "unclear, " and "not applicable." To perform the quality appraisal assessment, the two co-authors (M.J. and N.D.) independently assessed the quality of each study based on each question, compared their results, and discussed any incongruence to reach a consensus.This assessment tool does not have specific guidelines on grading or cut-off points for inclusion.Thus, we calculated the score by assigning one point to each question, resulting in a total score of 10.

Data extraction and synthesis
We utilized the data extraction and synthesis methods described by Sandelowski and Barroso [25].According to these scholars, the goal of this meta-synthesis is to summarize and re-analyze the findings from each study to derive the main themes.Our goal in synthesizing the included qualitative studies was to find fathers' perspectives that were the most indicative of their influence on children's health behaviors.
In this process, we created a data matrix to record the extracted articles.The matrix included aspects such as the study design, geographic area, sample characteristics (sample size, interviewees' age range, children's age range, race, and ethnicity), data collection methods, and data analysis methods.The co-authors (E.P. and N.D.) extracted all the quotes and themes from each study.Of the studies that included data on both parents, only quotes made by the fathers were retained [26,27].
All the extracted quotes were inputted onto an Excel spreadsheet and re-coded.Although the responses could differ depending on the data collection approach used (i.e., interviews or focus groups), we depended solely on the data presented in primary studies.All the quotesand themes supported by the quotes-were derived from the primary studies included in the meta-synthesis.The data analysis was conducted using a thematic approach.Two co-authors (E.P. and M.J.) with experience and expertise in qualitative research independently coded the quotes and reached an agreement through thorough comparisons of the codes and frequent discussions.If the coders noticed any discrepancy in specific codes, they checked how specific quotes were used to support the themes in the primary studies and then reached consensus.After all the data were coded, they were iteratively reviewed and collapsed into categories with similar meanings.Furthermore, themes and overarching themes were derived.

Study selection
Database and manual searches yielded 1,242 and 117 studies, respectively.After the initial screening, 1,151 studies were excluded.After a full-text screening of 67 studies, we further excluded 54 studies for the following reasons: they did not target fathers (n = 41), did not focus on children's health behaviors related to obesity (n = 6), did not target children aged 2-18 years (n = 6), or targeted fathers' experience of weight management of children (n = 1).Finally, 13 studies were included in this qualitative meta-analysis.The article selection process is illustrated in Fig. 1.

Study description
Among the 13 qualitative studies, the sample sizes ranged from 8 to 117, and the data were collected through individual interviews, focus groups, or surveys with openended questions.Participants were recruited using either convenience sampling or purposive sampling methods.In one study, fathers were recruited from the worksite [28], and in two, fathers were recruited from specific ethnic communities [27,29].In two studies, fathers and mothers participated in focus group interviews [26,27], whereas in the remaining studies, only fathers participated in individual interviews.The target age of the children varied across the studies but was mostly within the range of 2-10 years, and in three studies, fathers of children aged 3-6 years were included [26,30,31].Of the studies that specified the race or ethnicity of the participants, three comprised only Latinos or Mexican Americans [19,27,29], and one comprised only African Americans [32]; in the remaining studies, participants comprised different races and ethnicities.Most studies used thematic analysis for data analysis; however, three studies used the ground theory approach [27,28,32], and one used the content analysis method [30].

Quality appraisal
Quality assessment scores were used to interpret the studies and synthesize their outcomes.Quality scores ranged from 7 to 8 (out of 10) (Table 1).As the quality of the study findings was consistently high across studies, we did not exclude any articles based on our quality assessment.

Overarching themes
Three overarching themes were derived: (1) fathers' parenting practices and role-modeling behaviors, (2) fathers' roles in their relationships with other family members, and (3) fathers' resource-seeking behaviors and contributions to their home food environment.These themes represent fathers' perspectives on their influence on children's health behaviors.Examples of quotes depicting each overarching theme and subtheme are presented in Table 2.

Fathers' parenting practices and role-modeling behaviors
Fathers' parenting practices, in this context, refer to behavioral strategies that guide their children's health behaviors that relate to childhood obesity.The role-modeling behavior of the fathers involved exhibiting behavioral examples that influenced children through emulation.Fathers' attitudes, beliefs, perceptions, and knowledge regarding diet and physical activity can shape their parenting practices and role-modeling behaviors that guide their children's health behaviors.

Fathers' parenting practices
Fathers noted that their parenting practices may affect the healthy or unhealthy behaviors of children related to obesity in childhood.First, fathers reported certain parenting practices that could influence their children's healthy behaviors.For example, fathers encouraged their children's autonomy by letting them choose what they want to eat among various healthy options, respecting their children's preferences, and negotiating with their children to guide them in choosing healthy options [27].Fathers also introduced "new things to the kids" continuously, thus allowing their children to become familiar with diverse foods [18].They also reported parenting practices with structural features, such as feeding on a schedule and setting rules regarding the eating environment (e.g., location of the meals, not watching television during meals, finishing a meal, types of food to be consumed, and the amount of food) [18].Some fathers perceived mealtime as an important time for the family and considered food a means to bring the family together [31].They also believed that mealtimes were a social event for helping children learn social skills [31].Moreover, fathers indicated being in charge of their children's physical activities; as one father stated, "It [physical activity] is my domain…" [20].Fathers usually engage in setting a routine physical activity for their children [27].Some fathers also exhibited certain parenting practices that could be considered unhealthy.For example, they pushed their children to eat more [18] and used food as a reward to entice their children to eat other foods or promote non-food-related behaviors, such as reducing television viewing or playtime [18,29].In such cases, fathers usually presented high-energy-dense sugary foods as a reward.Furthermore, some fathers recognized that their children were "spoiled"; for example, one father stated that he "tried to give him what he wants [to eat]" [18].They also used media such as TV to distract their children while feeding them [18].

Fathers' role-modeling behaviors
Fathers were aware of their influence as role models.In addition to perceiving their critical roles in modeling good behaviors, they fathers recognized that they have a responsibility in shaping their children's health behaviors [31].Thus, fathers attempted to eat healthy foods, exercise more often, and avoided engaging in sedentary behaviors.A father stated, "[my] words, [my] actions, and [my] behaviors have a great impact" and "so, what they learn from us is eventually what will shape their character" [31].A father stated, "They think you're not doing it so why should they" [31].Notably, the fathers indicated that they played a major role in influencing their children's engagement in physical activities.Another father stated that he tried actively participating in physical activities because he thought his children would follow his behavior [31].Another father attempted to accompany his children during their structured activities, "… running, exercising the entire time they are so they can see" [20].
However, fathers often failed to adhere to healthy behaviors because of their unhealthy dietary habits such as a high intake of soda, or because of their proclivity toward sedentary behavior [30].Although these fathers were aware of their roles as models for their children, they had difficulty managing conflicts because of their preferences and behaviors.

Fathers' roles in their relationship with their family members
The fathers' influence on children's health behaviors was integrated with the nature of their relationships with their family members.The father's role could be described based on whether they shared responsibilities in childcare and household work with their spouses rather than staying in their traditional role and whether their parenting practices were similar to those of their spouses.The fathers also identified encouraging children to be involved in various activities as a significant role.

Shared childcare and household responsibilities with spouses
From the point of view of fathers, collaborative responsibility-sharing with their spouses emerged as a pivotal factor that influences their active involvement in parenting practices and, thereby, impacts their children's health behaviors associated with obesity.Some fathers shared responsibilities with their spouses by taking charge of household work to promote their children's healthy behaviors.One father stated that he and his wife split the work "right down the middle" [33].The method of sharing responsibilities differed slightly across families.One father stated that he and his wife divided their household responsibilities, including cooking and childcare, based on the days of the week or hours of the day [33].Another father reported that he oversaw specific tasks, such as grocery shopping, whereas she oversaw meal planning [33].One father and his spouse worked together, doing the "same thing at the same time, " and indicated that they "both cook for [children] together" [33].
However, some fathers ascribed traditional gender roles to housework.They thought that cooking was their spouse's responsibility; thus, they left it up to the spouse's decision and practices [27].One father indicated that household tasks were his spouse's work by stating that "my wife is the one that decides and she has everything prepared" [36], and the menu is determined by what their spouse selects [19].Another father reported that his "wife is the CEO of domestic duties" [26].These fathers' reluctance to participate in household tasks and childcare stems from their stereotypical perception of gender roles, which could impede their active engagement in parenting practices to promote children's healthy behaviors.

Similarity in the fathers' and their spouses' parenting practices
Fathers acknowledged that the congruence or discordance between their approaches and their spouses' parenting practices significantly impacted their children's obesity-related behaviors.Some fathers adopted parenting practices similar to those of their spouses.A father reported that he and his spouse were "on the same page 'about the diet option" [33].One father stated that he supported his spouse's thoughts and ideas regarding the importance of mealtime because they shared similar perspectives [33].A father stated that two parents need to cooperate, share the tasks, and stick to the plan if both agree [35].However, some fathers reported conflicts with their spouses regarding their parenting practices.For example, some fathers considered their spouses' parenting practices to be unhealthy and thought that these practices influenced their children toward unhealthy behaviors [29].One father reported that the children were "spoiled" because of how their mother fed them [29].Regarding limiting screen time, a father stated that "I would take his game away, and his mother would come and give it back to him" [29].

Involvement of the children in activities
Fathers interacted with their children and attempted to involve them in various activities, such as grocery shopping, eating together, and playing outside [28,33].Fathers considered these activities as "bonding time" with their children [27], noting that doing such activities with their children added "another level of bonding" [20] in their relationship.Fathers indicated that they played a significant role in their children's physical activities; they were in charge of planning their children's physical activities, and when they were active, they engaged in such activities with their children [20].
Fathers identified several challenges involving their children in their activities, including electronic media and children's resistance.One father reported that "… smartphones and the like have become a way of life for the coming generations" [30].Other media devices, such as televisions and iPads, have also been identified as challenges to fathers' ability to encourage their children to be physically active [28].The resistance of children to healthy options was another barrier identified.Fathers stated that it was a challenge impeding their children from choosing healthy options.One father reported that when he offered homemade food to his child, "they say no" and preferred to eat "food from outside" [29].

Fathers' resource-seeking behaviors and contributions toward their home food environment
Seeking the available resources and contributing to the physical home environment (i.e., the home food environment) were other important factors affecting fathers' influence over their children's health behaviors.Conversely, feeling frustrated owing to limited resources and challenging home food environments was identified as a challenge to improving their children's health behaviors.

Seeking available resources
Fathers sought available resources to support their children's healthy behaviors but felt frustrated when they perceived a lack of sufficient resources.Some fathers reached out to their healthcare providers for valuable information and considered such information a resource to promote healthy behavior among children.One father stated, "I would consult the pediatrician and make sure they are eating a healthy, well-balanced diet to get their weight under control." [30].
However, fathers perceived healthy food options as more expensive and were frustrated if they could not afford these options because of financial restrictions.One father reported, "I noticed eating healthy, it costs money, it's kinda expensive" [32].Furthermore, fathers highlighted time constraints when both parents work full time; this situation leads them to choose simple solutions, such as choosing fast foods for their children [35].Fathers indicated that they did not have enough time to engage in healthy lifestyle choices by stating that "people have less time so it's about food that's easy to prepare, which is processed, " and they noticed that such options are "typically like high in calories and low nutritional value" [31].

Contribution to their home food environment
Some fathers identified the home food environment as a facilitator of healthy food intake among their children.They purchased healthy foods to provide their children with healthy food choices.One father reported that "we try to make a variety of food [available]…" [28].However, if the father preferred unhealthy foods, such as soda or high-calorie foods, they "fell into bad habits" and tended to have them in the house, potentially rendering such foods available to their children [30].

Discussion
To date, there is a paucity of information on how to improve fathers' role in addressing childhood obesity because fathers have been underrepresented in studies on childhood obesity.We contributed to meeting the knowledge and literature gap by synthesizing the findings of 13 qualitative studies to clarify paternal perspectives regarding their influence on children's health behaviors.From the qualitative studies reviewed, we found evidence that fathers are aware of their influence on children's health behaviors.Their parenting practices and role-modeling behaviors were among the most commonly addressed, consistent with known parental roles in children's health behaviors [5].Furthermore, fathers were cognizant of the importance of their relationships with other family members, which could be understood in terms of their role within the familial relationship.We suggest that these fathers' perspectives be incorporated into observational studies to examine the relationship between fathers' roles and children's health behaviors to design further intervention programs to improve these behaviors.
We found that the analyses of fathers regarding the common parental role of influencing children's eating habits and physical activities primarily focused on the related healthy or unhealthy parenting practices.Healthy parenting practices include respecting children's autonomy in selecting healthy food options, introducing new foods to facilitate their familiarity with diverse foods, and setting structures around the mealtime routine.According to previous studies, both healthy eating behaviors and lower body mass index in children are associated with the frequency of family mealtimes [37,38].Our metaanalysis reveals that this relationship may be related to fathers' healthy food-related parenting practices during mealtime.Reported unhealthy parenting practices included impelling children to eat more, using food as rewards to encourage certain behaviors, feeding children whatever they want, and using media as a tool to distract children while feeding.Such unhealthy parenting practices are consistent with those reported in earlier works on the factors influencing children's unhealthy eating behaviors.According to a previous study, parenting practices, including parental pressure to eat, can disrupt the development of children's self-regulation in response to hunger [39].Additionally, children tend to be more responsive when parents use food as a reward [40].
Fathers also recognized that their behavior could serve as a model for their children.This is consistent with previous findings regarding the father as a role model for children's behavior [41].In the studies reviewed, physical activity was identified as the main behavior that fathers may model for their children.Some fathers recognized the benefits of physical activity and attempted to be more active in front of their children.This finding emphasizes fathers' greater role in arranging physical activities than mothers [42].Although fathers were aware of their role as models, some of them failed to adhere to healthy options because of their proclivity toward unhealthy behaviors.In a cross-sectional study of minority families, half of the participating parents exhibited unhealthy modeling behaviors, although the authors did not specify which parents' role-modeling behaviors were associated with children's health behaviors [43].This finding indicates that adults may need to improve their health behaviors to improve their health as well as encourage their children's healthy behaviors.
A notable perspective identified in the present metasynthesis was fathers' perception of their role in their relationships with family members.Their role was described in terms of their participation in childcare and household work, specifically, whether they worked with their spouses and children.Some fathers were more likely to share childcare and household responsibilities with their spouses than others were.Traditionally, fathers are viewed as additional caregivers or supporters of the primary caregiver; in the studies reviewed, fathers' perceptions varied from active engagement in childcare by interacting with their spouses to maintenance of the traditional gender role in the family.
Shared parenting responsibilities and similarities in healthy parenting practices lead to positive cognitive [44] and behavioral [45] outcomes among children.Consistent with these findings, taking responsibility for childcare and performing parenting practices similar to those of spouses could be important factors affecting children's health behaviors.However, according to one previous study, fathers and mothers could have different parenting practices with different influences on their children's health behaviors [7].For example, the researchers found that, compared to fathers, mothers were more likely to use limit setting (e.g., limiting weekly television and videogame time) and monitoring (e.g., keeping track of the amount of exercise the child received) and less likely to use control (e.g., ensuring that children always finished the food on their plate) [7].The differences between the parenting practices of fathers and mothers may be understood in the context of fathers' perceptions of their role in their spousal relationship, as observed in the studies reviewed in this meta-synthesis.
Fathers also indicated the importance of interacting with their children.In the reviewed studies, some fathers perceived engaging in activities with their children as an opportunity to build relationships with them, and the degree of closeness between fathers and their children is positively associated with children's body mass index [46].Thus, interactions between fathers and children during certain activities, including eating and physical activities, may be an important factor for improving children's health behaviors [47].In our meta-synthesis, some fathers reported that they attempted to involve their children in grocery shopping and physical activities and felt connected with their children during this time.Consistent with this finding, fathers' perspectives on the extent to which they participate in childcare are related to their positive influence on children's health behaviors [48].
Seeking available resources and contributing to the physical home environment were identified as factors influencing children's health behaviors.The availability of the right resources is known to influence children's health behaviors and childhood obesity [36,49].Fathers' active resource-seeking behaviors could be a potential factor in improving children's health behaviors.Prior research has also found that the physical home food environment (i.e., availability of homemade food) is a significant factor affecting children's dietary patterns [50,51].Children develop their dietary patterns and food preferences based on what is available in their home food environment as they observe their parents' preparation and selection of foods [52].In studies reviewed, many fathers contributed to establishing the home food environment by purchasing healthy foods to provide healthy food choices to their children.However, fathers who preferred to consume soda or high-calorie foods tended to stock them at home, which also made these unhealthy options available to their children.

Limitations
There are some limitations in interpreting the outcomes of the present study.In four of the 13 studies, fathers from Hispanic or African American families were recruited; thus, the role of family members should be understood from their cultural perspective.Furthermore, given the heterogeneity of the samples (e.g., child age range and racial or ethnic composition), different study methodologies (e.g., data collection approach and analysis methods), and the overall diversity of the included primary studies, it was challenging to synthesize the study findings.Finally, our process of retrieving the relevant literature may not have been comprehensive because we included only peer-reviewed journals.

Implications
Despite the limitations of this study, our qualitative meta-synthesis provides potential recommendations for nursing practice, research, and policy.In nursing education, nurses may need to emphasize the role of fathers in improving children's health behaviors.Thus, fathers would be aware of their significant influence on children's health behaviors and actively participate in childcare by working with their spouses.Although several fathers recognized their influence on children's health behaviors, mothers and fathers may share different perspectives on their respective parenting roles.
In future nursing research, researchers may consider comparing the perceptions of fathers' and mothers' influences on their children's health behaviors using diverse approaches, such as objective measures of behaviors.Furthermore, more research is needed to understand how fathers can actively engage in childcare and define how parents can work together to encourage fathers' active participation in childcare and household work.Moreover, few studies have targeted fathers of adolescents, and more research is needed to explore the influence of fathers of adolescents on children's health behaviors.The fathers' perspectives on their influence on children's health behaviors identified in this study could be used to develop interventions to improve fathers' parenting practices, role-modeling behaviors, and relationships with their spouses and children.Therefore, fathers could be included in family-based interventions to reduce childhood obesity.Intervention research focusing on fathers' role in establishing children's healthy behaviors could be conducted in a way that encourages joint activities among family members, such as physical or fun cooking activities [53,54].Furthermore, increasing the number of paternity leaves could be a policy measure to provide fathers with the opportunity to actively participate in parenting practices and spend more time with their families.

Conclusion
We synthesized 13 qualitative studies to understand fathers' perspectives regarding their influence on children's health behaviors related to childhood obesity.Through a qualitative meta-synthesis, we found that fathers were aware of their parenting practice role-modeling behaviors that could influence their children's health behaviors.In addition, fathers' perspectives on their influence over their children's health behaviors could be understood in terms of their relationships with their spouses and other children; that is, whether they shared household and childcare responsibilities with their spouses and involved their children in various activities.Based on the findings of this review, nursing researchers would further investigate possible approaches for improving fathers' roles in establishing children's healthy behaviors-particularly the behaviors related to obesity-with an understanding of the family dynamics in a cultural context.

Fig. 1
Fig. 1 Flow of the literature searching and screening

Table 2
Themes and example quote

Table 2
(continued) My wife and I split things pretty 50-50, right down the middle.She's really in charge of Thursday, Friday and Saturdays, and I'm able to be there Monday, Tuesday, Wednesday.I do most of the cooking in the evenings when I'm at home.She takes the day, and I take the night." Khandpur 2016, p 458 "Me and my wife, we try to split the responsibilities for cooking.As far as groceries go we both do it together.We don't have a car.It makes it easier if we're both together to help carry stuff in.I enjoy going shopping because I like to introduce new things to the kids once in a while and open up their minds a little bit to trying new stuff."